Chronic morbidity of corneal infiltrative events associated with contact lens wear

Corneal ring infiltrate- far more than Acanthamoeba keratitis: review of pathophysiology, morphology, differential diagnosis and management

OBJECTIVE

Ring infiltrates usually accompany numerous infectious and sterile ocular disorders. Nevertheless, systemic conditions, drugs toxicity and contact lens wear may present with corneal ring infiltrate in substantial part. Considering its detrimental effect on vision, detailed knowledge on etiology, pathophysiology, differential diagnosis, and management should be considered essential for every ophthalmologist.

METHODS

The PUBMED database was searched for "corneal ring infiltrate" and "ring infiltrate" phrases, "sterile corneal infiltrate" and "corneal infiltrate". We analyzed articles written in English on risk factors, pathophysiology, clinical manifestation, morphological features, ancillary tests (anterior-segment optical coherence tomography, corneal scraping, in vivo confocal microscopy), differential diagnosis and management of corneal ring infiltrate.

RESULTS

Available literature depicts multifactorial origin of corneal ring infiltrate. Dual immunological pathophysiology, involving both antibodies-dependent and -independent complement activation, is underlined. Furthermore, we found that the worldwide most prevalent among non-infectious and infectious ring infiltrates are ring infiltrates related to contact-lens wear and bacterial keratitis respectively. Despite low incidence of Acanthamoeba keratitis, it manifests with corneal ring infiltrate with the highest proportion of the affected patients (one third). However, similar ring infiltrate might appear as a first sign of general diseases manifestation and require targeted treatment. Every corneal ring infiltrate with compromised epithelium should be scraped and treat as an infectious infiltrate until not proven otherwise. Of note, microbiological ulcer might also lead to immunological ring and therefore require anti-inflammatory treatment.

CONCLUSION

Corneal ring infiltrate might be triggered not only by ocular infectious and non-infectious factors, but also by systemic conditions. Clinical assessment is crucial for empirical diagnosis. Furthermore, treatment is targeted towards the underlying condition but should begin with anti-infectious regimen until not proven otherwise.

Current understanding and therapeutic management of contact lens associated sterile corneal infiltrates and microbial keratitis

Contact lenses are widely prescribed in clinical practice with multiple applications and advantages. However, contact lenses can be associated with various complications which range from innocuous to severe. Clinicians thus not only need to possess the ability to prescribe the most appropriate contact lenses for each individual patient but also be able to recognise and manage any associated complications. This review examines the existing literature on the management of corneal infiltrative events associated with soft contact lenses, including microbial keratitis, particularly in the context of practising in Australia. The definitions and diagnosis of corneal infiltrative events, as well as the current understanding of their aetiologies, will be explored. The various aspects of a successful management will be discussed, including the applications of therapeutic agents such as antimicrobial and anti-inflammatory agents, the role of microbiological investigations, and strategies to improve long-term prognosis. The currently available evidence supporting management options will be presented, highlighting the relative abundance of high-level evidence on management protocols, antimicrobial selection and treatment duration for microbial keratitis; and the relative paucity of studies and trials for sterile corneal infiltrative events, despite this condition being much more commonly encountered in clinical practice.

Ocular conditions and dry eye due to traditional and new forms of smoking: A review

Addiction to cigarette smoking has high prevalence rates recorded worldwide. Smoking has been linked to several life-threatening systemic conditions such as cancer, heart attack and stroke, in addition to a range of ocular pathologies. In recent years, electronic cigarettes (EC) have emerged as alternatives to smoking. ECs are nicotine delivery devices which produce an aerosol by heating, rather than combusting, a liquid which contains nicotine, flavours and preservatives. This review focuses on the association of traditional and new forms of smoking with dry eye disease, contact lens wear and four other common ocular diseases: cataract, age-related macular degeneration, glaucoma and Graves' ophthalmopathy. It is concluded that smoking and vaping appear as a risk factor for the aforementioned ocular conditions. An evidence-based, clear link between cigarette smoking, or EC vaping and ocular problems is yet to be discovered.

Characterizing Contact Lens-Related Corneal Infiltrates: A Pilot Study

Purpose:

To document the time course and resolution of contact lens–related corneal infiltrative events (CIEs) comparing slit-lamp images with anterior segment ocular coherence tomography (AS-OCT) images.

Methods:

Six silicone hydrogel (SiHy) soft contact lens (SCL) wearers presenting with newly diagnosed symptomatic CIEs were monitored with slit-lamp images, detailed drawings, and AS-OCT until the resolution of the CIE. A final follow-up visit was completed 4 weeks after CIE resolution to determine whether scar formation was present. Positive controls were 2 SiHy SCL wearers with established (inactive) corneal scars, and negative controls were 2 SiHy SCL wearers with clear corneas. High- and low-contrast logMAR visual acuities were measured, and subjective symptom questionnaires were completed at all visits.

Results:

Clinical signs, vision, and symptoms improved in tandem with the resolution of the CIEs as measured by imaging methods. Calibrated measures of infiltrate width from a slit-lamp biomicroscope appear to be similar to calibrated images from AS-OCT.

Conclusions:

Although further studies are needed to develop standardized procedures, AS-OCT can be a useful tool to characterize the development, progression, and resolution of corneal infiltrates as an objective measure of resolution and scar formation.

In Vivo Confocal Microscopy of the Cornea: New Developments in Image Acquisition, Reconstruction, and Analysis Using the HRT-Rostock Corneal Module

The optical sectioning ability of confocal microscopy allows high magnification images to be obtained from different depths within a thick tissue specimen and is thus ideally suited to the study of intact tissue in living subjects. In vivo confocal microscopy has been used in a variety of corneal research and clinical applications since its development over 25 years ago. In this article we review the latest developments in quantitative corneal imaging with the Heidelberg Retinal Tomograph with Rostock Corneal Module (HRT-RCM). We provide an overview of the unique strengths and weaknesses of the HRT-RCM. We discuss techniques for performing 3-D imaging with the HRT-RCM, including hardware and software modifications that allow full-thickness confocal microscopy through-focusing (CMTF) of the cornea, which can provide quantitative measurements of corneal sublayer thicknesses, stromal cell and extracellular matrix backscatter, and depth-dependent changes in corneal keratocyte density. We also review current approaches for quantitative imaging of the subbasal nerve plexus, which require a combination of advanced image acquisition and analysis procedures, including wide-field mapping and 3-D reconstruction of nerve structures. The development of new hardware, software, and acquisition techniques continues to expand the number of applications of the HRT-RCM for quantitative in vivo corneal imaging at the cellular level. Knowledge of these rapidly evolving strategies should benefit corneal clinicians and basic scientists alike.

In vivo confocal microscopy of the ocular surface: from bench to bedside

In vivo confocal microscopy (IVCM) is an emerging technology that provides minimally invasive, high resolution, steady-state assessment of the ocular surface at the cellular level. Several challenges still remain but, at present, IVCM may be considered a promising technique for clinical diagnosis and management. This mini-review summarizes some key findings in IVCM of the ocular surface, focusing on recent and promising attempts to move "from bench to bedside". IVCM allows prompt diagnosis, disease course follow-up, and management of potentially blinding atypical forms of infectious processes, such as acanthamoeba and fungal keratitis. This technology has improved our knowledge of corneal alterations and some of the processes that affect the visual outcome after lamellar keratoplasty and excimer keratorefractive surgery. In dry eye disease, IVCM has provided new information on the whole-ocular surface morphofunctional unit. It has also improved understanding of pathophysiologic mechanisms and helped in the assessment of prognosis and treatment. IVCM is particularly useful in the study of corneal nerves, enabling description of the morphology, density, and disease- or surgically induced alterations of nerves, particularly the subbasal nerve plexus. In glaucoma, IVCM constitutes an important aid to evaluate filtering blebs, to better understand the conjunctival wound healing process, and to assess corneal changes induced by topical antiglaucoma medications and their preservatives. IVCM has significantly enhanced our understanding of the ocular response to contact lens wear. It has provided new perspectives at a cellular level on a wide range of contact lens complications, revealing findings that were not previously possible to image in the living human eye. The final section of this mini-review provides a focus on advances in confocal microscopy imaging. These include 2D wide-field mapping, 3D reconstruction of the cornea and automated image analysis.

The Glenn A. Fry award lecture 2010: Ophthalmic markers of diabetic neuropathy

Diabetic peripheral neuropathy (DPN) is a debilitating condition that affects about 50% of diabetic patients. The symptoms of DPN include numbness, tingling, or pain in the arms and legs. Patients with numbness may be unaware of foot trauma, which could develop into a foot ulcer. If left untreated, this may ultimately require amputation. Currently, the only method of directly examining peripheral nerves is to conduct skin punch or sural/peroneal nerve biopsies, which are uncomfortable and invasive. Indirect methods include quantitative sensory testing (assessing responses to heat, cold, and vibration) and nerve electrophysiology. Here, I describe research undertaken in my laboratory, investigating the possibility of using a range of ophthalmic markers to assess DPN. Corneal nerve structure and function can be assessed using corneal confocal microscopy and non-contact corneal esthesiometry, respectively. Retinal nerve structure and visual function can be evaluated using optical coherence tomography and perimetry, respectively. These techniques have been used to demonstrate that DPN is associated with morphological degradation of corneal nerves, reduced corneal sensitivity, retinal nerve fiber layer thinning, and peripheral visual field loss. With further validation, these ophthalmic markers could become established as rapid, painless, non-invasive, sensitive, reiterative, cost-effective, and clinically accessible means of screening for early detection, diagnosis, staging severity, and monitoring progression of DPN, as well as assessing the effectiveness of possible therapeutic interventions. Looking to the future, this research may pave the way for an expanded role for the ophthalmic professions in diabetes management.